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International Journal of Nursing Studies 47 (2010) 279–286

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International Journal of Nursing Studies
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Evaluating the effect of the new incentive system for high-risk pressure ulcer patients on wound healing and cost-effectiveness: A cohort study
Hiromi Sanada a,1,*, Gojiro Nakagami a,1, Yuko Mizokami b,Yukiko Minami b, Aya Yamamoto b, Makoto Oe a, Toshiko Kaitani a, Shinji Iizaka a
a b

Department of Gerontological Nursing/Wound Care Management, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan Japanese Association of Enterostomal Therapy Nurses/Wound Ostomy and Continence Nurses, Japan



Article history: Received 15 January 2009Received in revised form 4 June 2009 Accepted 11 August 2009 Keywords: Health insurance Staffing Economic evaluation

Objective: To evaluate the effectiveness and cost-effectiveness of new incentive system for pressure ulcer management, which focused on skilled nurse staffing in terms of rate of healing and medical costs. Design, setting and participants: A prospective cohort study included two typesof groups: 39 institutions, which introduced the new incentive system, and 20 non-introduced groups (control). Sixty-seven patients suffering from severe pressure ulcers in the introduced group and 38 patients in the non-introduced group were included. Wound healing and medical costs were monitored weekly for three weeks by their skilled nurses in charge. Main outcome measures: Healing status andrelated medical costs. Results: The introduced group showed significantly higher rate of healing compared with the control group at each weekly assessment. Multiple regression analysis revealed that the introduction of the new incentive system was independently associated with the faster healing rate (b = 3.44, P < .001). The budget impact analysis demonstrated that introducing this system couldreduce cost of treating severe pressure ulcers by 1.776 billion yen per year. Conclusions: The new incentive system for the management of pressure ulcers, which focused on staffing with skilled nurses can improve healing rate with reduced medical cost. ß 2009 Elsevier Ltd. All rights reserved.

What is already known about the topic?  Pressure ulcers are common complications in acute care setting. Many national strategies have been introduced for preventing its occurrence; however no drastic reduction occurred.

 In Japan, new incentive system was introduced in order to not only prevent pressure ulcer development but also improve the treatment of severe pressure ulcers. What this paper adds  Introduction of new incentive system led to significantly faster healing of severe pressureulcers and greater costeffectiveness for the management of pressure ulcers.  New evidence focusing on staffing with skilled nurse for the effective pressure ulcer management strategy was clearly established.

* Corresponding author at: Faculty of Medicine Bldg. No. 5-306, 7-3-1, Hongo, Bunkyo-ku, Tokyo 113-0033, Japan. Tel.: +81 3 5841 3419; fax: +81 3 5841 3419. E-mail (H. Sanada). 1 These authors equally contributed to this manuscript. 0020-7489/$ – see front matter ß 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijnurstu.2009.08.001


H. Sanada et al. / International Journal of Nursing Studies 47 (2010) 279–286

1. Introduction Pressure ulcers are common complications in both elderly and acute-care patients with the prevalence rangingfrom 14.3% to 15.6% in acute care settings to 27.7% in long-term care facilities (Horn et al., 2002; Whittington and Briones, 2004). In Japan, the prevalence is relatively low compared with the United States; 3.64% in acute care settings, however, once the pressure ulcer has developed, it tends to deteriorate owing to the patient’s physical characteristics, such as extreme bony prominence, and...
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